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U GROUND TANK OFFICIAL INSPECTION R1,FRT SAN JOAQUIN PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N.San Joaquin Street Mailing Address: P.O.Box 388 COUNTY NAME Stockton,CA 95201-0388 COUNTY 468-3420 SITE NAME: INSPECTION DATE: SITE ADDRESS: CITY/STATE/ZIP CHANGES SITE YES NO TANK TANK TANK TANK FORM A AND/OR B SUBMITTED? COMPUTECOMP* ER� COMP ER COMPO TE® INSPTION SITE COMPUTER# NUMBER ` NUMB NUMB NUMBE YP PER PER#�Cl PER# PER# 1 EXP.DATE EXP. AT EXP. A EXP.DATE OPERATIONAL TANK TANK CONTENTS MAJOR MINOR w PERMIT TO OPERATE 1 2 CHANGE IN CONDITIONS TO OPERATE 3 4 _14' 'TEf"1 STATUS REPOPT APPROVED CONSTRUCTION 5 6 — — — — — — AI I. r UNCT IONS NORMAL WRITTEN MONITORING PROCEDURES 7 8 APPROVED MONITORING SYSTEM 9 10 MONITORING SYSTEM 11 12 APPROVED MONITOR FREQUENCY 13 14 MONITORING RECORDS MAINTAINED 15 16 ACCESS CASING SECURED 17 18 PIPING 19 20 INVENTORY RECONCILIATION 21 22 L TANK GAUGING 23 24 ....... APPROVED RESPONSE PLAN 25 26 510 1 UNAUTHORIZED RELEASE OCCURRENCE 27 28 AH SAMPLING 29 30 APPROVED TANK REPAIRS 31 32 UNAUTHORIZED RELEASES REPORTED 33 34 _.... .. ........ L FT SAFETY HAZARD 35 36 .IAL CONDITIONS ABATED 37 TEMPORARY TANK CLOSURE REMOVAL OF RESIDUAL 38 139 1_ li 07 GALS FLAMMABLE VAPORS REMOVED 40 'r- - r`498 GALS 1697 ,ALS ACCESS LOCATIONS SEALED 41 42r,l_arlE = 1007 CALS POWER DISCONNECTED q3 - '� I NC:HES _3. _. �. . ITh — 0.t.iu I NCHES OWNER/OPERATOR MONITORING 44 45 f"1 ' �,q. I DEG F PERMANENT TANK CLOSURE q REMOVAL OF RESIDUAL MATERIALS 46 47 PIPING 48 49 FLAMMABLE VAPORS REMOVED 50 UNAUTHORIZED RELEASE 51 52 SAMPLING 53 54 IMPROPER ABANDONMENT 55 56 THE MARKED ITEMS REPRESENT VIOLATIONS ANO MUST BE CORRECTED AS SYSTEM STATUS(MUST MARK ONE) FOLLOWS: MAJOR 57 MINOR 58 59 NO VIOL. VIOL. ❑ VIOL. OFFICE: INSP RECEIV BY: TITLE: PHONE: BECK: HUT®3 White-Or!oinal Yellow-Owner's Copy Pink-File Ccov M